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Zhang X, Xie Y, Wang L. Rare Cutaneous Side Effects of Imiquimod: A Review on Its Mechanisms, Diagnosis, and Management. Dermatol Ther (Heidelb) 2023; 13:1909-1934. [PMID: 37528289 PMCID: PMC10442311 DOI: 10.1007/s13555-023-00978-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Accepted: 07/05/2023] [Indexed: 08/03/2023] Open
Abstract
As an immune-response modifier, imiquimod can bind to Toll-like receptors on immune cells and enhance innate and adaptive immune responses, exerting potential antitumor and antiviral effects, which led to its approval by the US Food and Drug Administration for the treatment of actinic keratosis, superficial basal cell carcinomas, and anogenital warts, and to its off-label use in treating many other benign and malignant dermatoses. Although topical administration of imiquimod has been considered well tolerated, an increasing number of cutaneous and noncutaneous side effects are being reported as its clinical applications expand. This review primarily focuses on rare cutaneous side effects. To the best of our knowledge, this is the first article to summarize the mechanism, diagnosis, and management of rare cutaneous side effects of imiquimod, which may help to heighten awareness among physicians, especially dermatologists, about potential imiquimod-induced cutaneous side effects.
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Affiliation(s)
- Xiaoyan Zhang
- Department of Dermatovenereology, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, China
| | - Yao Xie
- Department of Dermatovenereology, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, China
| | - Lin Wang
- Department of Dermatovenereology, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, China.
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Fay CJ, Jakuboski S, Mclellan B, Allais BS, Semenov Y, Larocca CA, LeBoeuf NR. Diagnosis and Management of Dermatologic Adverse Events from Systemic Melanoma Therapies. Am J Clin Dermatol 2023; 24:765-785. [PMID: 37395930 PMCID: PMC10796164 DOI: 10.1007/s40257-023-00790-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/02/2023] [Indexed: 07/04/2023]
Abstract
The advent of protein kinase inhibitors and immunotherapy has profoundly improved the management of advanced melanoma. However, with these therapeutic advancements also come drug-related toxicities that have the potential to affect various organ systems. We review dermatologic adverse events from targeted (including BRAF and MEK inhibitor-related) and less commonly used melanoma treatments, with a focus on diagnosis and management. As immunotherapy-related toxicities have been extensively reviewed, herein, we discuss injectable talimogene laherparepvec and touch on recent breakthroughs in the immunotherapy space. Dermatologic adverse events may severely impact quality of life and are associated with response and survival. It is therefore essential that clinicians are aware of their diverse presentations and management strategies.
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Affiliation(s)
- Christopher J Fay
- Department of Dermatology, Brigham and Women's Hospital, and the Center for Cutaneous Oncology, Dana-Farber/Brigham and Women's Cancer Center, Harvard Medical School, Boston, MA, USA
| | | | - Beth Mclellan
- Department of Dermatology, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Blair S Allais
- Department of Dermatology, Brigham and Women's Hospital, and the Center for Cutaneous Oncology, Dana-Farber/Brigham and Women's Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Yevgeniy Semenov
- Department of Dermatology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Cecilia A Larocca
- Department of Dermatology, Brigham and Women's Hospital, and the Center for Cutaneous Oncology, Dana-Farber/Brigham and Women's Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Nicole R LeBoeuf
- Department of Dermatology, Brigham and Women's Hospital, and the Center for Cutaneous Oncology, Dana-Farber/Brigham and Women's Cancer Center, Harvard Medical School, Boston, MA, USA.
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Yu H, Cen J, Lin X, Cheng H, Seifert O. Imiquimod induced vitiligo-like lesions-A consequence of modified melanocyte function. IMMUNITY INFLAMMATION AND DISEASE 2021; 10:70-77. [PMID: 34614305 PMCID: PMC8669695 DOI: 10.1002/iid3.543] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 09/10/2021] [Accepted: 09/22/2021] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Imiquimod plays an important role in the management of condyloma and premalignant lesions. Successively, an increase of hypopigmented lesions following imiquimod application has been reported. However, the mechanisms of imiquimod on melanocytes remain unclear. This study was designed to assess the effect of Imiquimod on the functions of melanocytes in vitro. METHODS Primary cultured melanocytes were isolated from normal control skin tissue. After incubation with imiquimod for 48 h in vitro, cell viability was analyzed by cell counting kit-8 assay. Apoptosis was detected using the Annexin V-fluorescein-5-isothiocyanate flow cytometry assay. Melanin content and tyrosinase activity in melanocytes were measured by colorimetric method and the modified dopachrome method. The production of inflammatory cytokine interleukin 8 (IL-8), IL-6, and soluble ICAM-1 (soluble Intercellular Adhesion Molecule-1[sICAM-1]) in melanocytes were measured by enzyme-linked immunosorbent assay (ELISA). Toll-like receptor 7 (TLR7), toll-like receptor 9 (TLR9) protein, and autophagy-related proteins microtubule-associated protein 1A/1B-light chain 3 (LC3-II), p62, mechanistic target of rapamycin (mTOR), and Atg5 were assessed using western blot analysis. RESULTS Imiquimod significantly inhibited the activity of tyrosinase activity and decreased melanin content in melanocytes and significantly increased apoptosis and IL-6, IL-8, and sICAM-1 production in melanocytes. Moreover, the expression of TLR7 and TLR9 proteins were significantly increased, and the expression of mTOR, p62 protein were markedly decreased, but the expression of LC3II/I and Atg5 protein were significantly increased in melanocytes after incubating with imiquimod. CONCLUSIONS This study shows that imiquimod directly inhibits melanogenesis and increases melanocyte apoptosis rates. These effects combined with the upregulation of TLR7 and TLR9 together with increased autophagy activity and inflammatory cytokines production, might be the main reasons leading to hypopigmented lesions after imiquimod application.
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Affiliation(s)
- Haiyan Yu
- Department of Dermatology, Sir Run Run Shaw Hospital, Zhejiang University Medical College, Hangzhou, Zhejiang, China
| | - Jianping Cen
- Department of Dermatology, Sir Run Run Shaw Hospital, Zhejiang University Medical College, Hangzhou, Zhejiang, China
| | - Xiaoxia Lin
- Department of Dermatology, Sir Run Run Shaw Hospital, Zhejiang University Medical College, Hangzhou, Zhejiang, China
| | - Hao Cheng
- Department of Dermatology, Sir Run Run Shaw Hospital, Zhejiang University Medical College, Hangzhou, Zhejiang, China
| | - Oliver Seifert
- Division of Dermatology and Venereology, Ryhov Hospital, Jönköping, Sweden.,Division of Cell Biology, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
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Husein-ElAhmed H, Fernandez-Pugnaire MA. Dermatoscopy-guided therapy of pigmented basal cell carcinoma with imiquimod. An Bras Dermatol 2017; 91:764-769. [PMID: 28099598 PMCID: PMC5193187 DOI: 10.1590/abd1806-4841.20165255] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2015] [Accepted: 11/17/2015] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND: Dermatoscopy is a non-invasive diagnostic tool used to examine skin lesions with an optical magnification. It has been suggested as a useful tool for monitoring therapeutic response in lentigo maligna patients treated with imiquimod. OBJECTIVE: To examine the accuracy of dermatoscopy as a tool to monitor the therapeutic response of pigmented basal cell carcinoma treated with imiquimod. METHOD: The authors designed a prospective study. Patients with pigmented basal cell carcinoma were included and data regarding the dermatoscopy features were collected following the Menzies criteria, prior to initiating the imiquimod treatment. Subsequent dermatoscopic evaluations were performed at weeks 4 and 8, following imiquimod discontinuation. RESULTS: Twenty lesions were included. The most common pigmented dermatoscopy features were large blue-grey ovoid nests (80%), followed by blue-grey globules (50%) and leaf-like areas (30%). No spoke wheel areas were observed. In 17 out of 20 patients, a response was noted during the first evaluation at 4 weeks, while the clearance was noted at the second check-up after 8 weeks. In two patients, the clearance was found at the initial evaluation at 4 weeks, while in one patient, the response remained unchanged. Blue-grey globules were the fastest to exhibit clearance (50% at week 4), followed by leaf-like areas (15%) and large blue-grey ovoid nests (6.25%). CONCLUSION: According to our results, dermatoscopic evaluation enhances the accuracy in the assessment of the clinical response to imiquimod in pigmented basal cell carcinoma.
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Serra MC, Menicanti C, Pennacchioli E, Tosti G. Vulvar vitiligo-like depigmentation and multiple halos of hypomelanosis at the trunk following treatment with imiquimod 5% cream for vulvar condylomata: casual or related events? An Bras Dermatol 2015; 89:806-7. [PMID: 25184923 PMCID: PMC4155962 DOI: 10.1590/abd1806-4841.20143058] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Accepted: 09/20/2013] [Indexed: 11/22/2022] Open
Abstract
A 25-year-old Caucasian female with multiple genital warts involving the vulvar area
was treated with imiquimod 5% cream. During follow-up the patient developed areas of
hypopigmentation at the site of application of imiquimod cream and areas of
hypomelanosis around multiple preexisting nevi of the trunk. At 18 months follow-up
genital depigmentation persisted and halo nevi of the trunk were still present.
Different mechanisms of imiquimod-induced depigmentation have been reported. Halo
nevi are considered expression of an autoimmune response. In the case presented here,
it might be conceivable that both vitiligo-like depigmentation at the site of
application and halo of hypomelanosis around melanocytic nevi have been induced by
the same immunologic mechanism elicited by topical application of imiquimod.
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Affiliation(s)
| | - Claudia Menicanti
- Dipartimento di Fisiopatologia Medico-Chirurgica, Ospedale Maggiore Policlinico, Fondazione IRCSS Ca' Granda, Milano, Italia
| | | | - Giulio Tosti
- Divisione Melanoma, Istituto Europeo di Oncologia, Milano, Italia
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Burnett CT, Kouba DJ. Imiquimod-induced depigmentation: report of two cases and review of the literature. Dermatol Surg 2012; 38:1872-5. [PMID: 22805097 DOI: 10.1111/j.1524-4725.2012.02512.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Christopher T Burnett
- Department of Dermatology, Henry Ford Hospital, 3031 West Grand Blvd., Detroit, MI 48202, USA.
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Topical treatment of cutaneous metastases of malignant melanoma using combined imiquimod and 5-fluorouracil. Invest New Drugs 2011; 30:1641-5. [DOI: 10.1007/s10637-011-9717-2] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2011] [Accepted: 07/01/2011] [Indexed: 10/18/2022]
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Lupus Erythematosus–Like Reaction in Imiquimod-Treated Skin: A Report of 2 Cases. Am J Dermatopathol 2011; 33:523-7. [DOI: 10.1097/dad.0b013e3181f2bf9e] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Arya V, Bansal M, Girard L, Arya S, Valluri A. Vitiligo at Injection Site of PEG-IFN-α 2a in Two Patients with Chronic Hepatitis C: Case Report and Literature Review. Case Rep Dermatol 2010; 2:156-164. [PMID: 21076689 PMCID: PMC2978742 DOI: 10.1159/000320207] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
A 72-year-old female and a 57-year-old male with chronic hepatitis C were treated with a combination therapy of pegylated interferon (PEG-IFN)-α 2a (180 μg s.c. once a week) and ribavirin (1,000 mg orally daily). This resulted in the destruction of melanocytes at the injection site in both patients. In the male patient, the depigmentation progressed to the surrounding skin area. The dermatologist concurred with vitiligo as the diagnosis in both patients. Injection and surrounding site vitiligo associated with PEG-IFN-α 2b treatment for hepatitis C was noticed in previous case studies. For the first time, the case reports below highlight the same immunological adverse event secondary to PEG IFN-α 2a/ribavirin combination therapy and explain, in part, the complex interaction between host immune response and viral genotype. In addition, we systematically review drug-induced vitiligo and autoimmune diseases associated with the depigmentation disorder.
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Affiliation(s)
- V Arya
- Wyckoff Heights Medical Center, Brooklyn, N.Y., USA
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Barr KL, Konia TH, Fung MA. Lupus erythematosus-like imiquimod reaction: a diagnostic pitfall. J Cutan Pathol 2010; 38:346-50. [PMID: 20726930 DOI: 10.1111/j.1600-0560.2010.01592.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Imiquimod (AldaraTM), a Toll-like receptor 7 agonist (TLR7), is known for its unique properties of being an immune response modifier and stimulator. Upon topical application, this TLR7 agonist triggers a cell-mediated immune response predominantly expressed by dendritic cells and monocytes. Local skin irritation at the application site involving erythema, pain, crusting and erosions is common and well documented. On the contrary, the specific histopathologic features associated with these treatment site reactions is not. Herein reported is a case where historical omission of imiquimod use for actinic keratosis complicated the histologic interpretation. We highlight a lupus erythematosus-like microscopic pattern and explore histopathologic features that could help in avoiding a diagnostic pitfall, as well as the relationship between TLR activation, cell-mediated immunity and skin histology.
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Affiliation(s)
- Keira L Barr
- Department of Dermatology and Pathology, University of California Davis Medical Center, Sacramento, CA, USA.
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Abstract
PURPOSE OF REVIEW This review addresses recent changes in the understanding and the treatment of vitiligo vulgaris. RECENT FINDINGS Two target genes for vitiligo have been identified, NACHT-leucine-rich-repeat protein-1 (NALP1), part of the inflammasome cascade, and tyrosinase, the enzyme that produces melanin. Identification of reactive oxidation species has furthered the understanding of melanocyte destruction. Comorbid autoimmune disease, including thyroid autoimmunity seen in 25%, is genetically linked to generalized vitiligo and is noted in both childhood vitiligo patients and their families. Screening for vitamin deficiencies and concurrent autoimmunity can be beneficial to the overall health of the child with vitiligo. About half of all vitiligo vulgaris patients have onset of their illness during childhood, causing increased psychological stress during the formative years. Fortunately, therapy has improved as well, with the development of newer topical agents for vitiligo, including topical calcineurin inhibitors; new topical combinations such as topical corticosteroids and calcipotriene; and new technological advances including narrowband ultraviolet B and excimer laser. SUMMARY A cyclic approach to therapy should be used wherein topical agents are altered every 6-8 months and technology is used as an alternative after achievement of maximal topical response. With cyclic therapy and early disease intervention, good cosmetic outcomes may be achievable, particularly in localized cases.
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Liu J, Man WY, Lv CZ, Song SP, Shi YJ, Elias PM, Man MQ. Epidermal permeability barrier recovery is delayed in vitiligo-involved sites. Skin Pharmacol Physiol 2010; 23:193-200. [PMID: 20185976 DOI: 10.1159/000288166] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2009] [Accepted: 01/07/2010] [Indexed: 01/17/2023]
Abstract
BACKGROUND/OBJECTIVES Prior studies have demonstrated that both the skin surface pH and epidermal permeability barrier function vary with skin pigmentation types. Although melanin deficiency is the main feature of vitiligo, alterations in cutaneous biophysical properties in vitiligo have not yet been well defined. In the present study, stratum corneum (SC) hydration, the skin surface pH and epidermal permeability barrier function in vitiligo were evaluated. METHODS A total of 30 volunteers with vitiligo comprising 19 males and 11 females aged 13-51 years (mean age: 27.91 +/- 2.06 years) were enrolled in this study. The skin surface pH, SC hydration, melanin/erythema index and transepidermal water loss (TEWL) were measured by respective probes connected to a Courage-Khazaka MPA5. SC integrity was determined by measuring the TEWL following each D-Squame application. The barrier recovery rate was assessed at 5 h following barrier disruption by repeated tape stripping. RESULTS In addition to SC hydration, both melanin and erythema index were significantly lower in vitiligo lesions than in contralateral, nonlesional sites, while no difference in skin surface pH between vitiligo-involved and uninvolved areas was observed. In addition, neither the basal TEWL nor SC integrity in the involved areas differed significantly from that in the uninvolved areas. However, barrier recovery in vitiligo-involved sites was significantly delayed in comparison with uninvolved sites (40.83 +/- 5.39% vs. 58.30 +/- 4.71%; t = 2.441; p < 0.02). CONCLUSION Barrier recovery following tape stripping of the SC is delayed in vitiligo. Therefore, improvement in epidermal permeability barrier function may be an important unrecognized factor to be considered in treating patients with vitiligo.
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Affiliation(s)
- J Liu
- Dalian Skin Disease Hospital, Dalian, The People's Republic of China
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Current awareness: Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2009. [DOI: 10.1002/pds.1846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Kim CH, Ahn JH, Kang SU, Hwang HS, Lee MH, Pyun JH, Kang HY. Imiquimod induces apoptosis of human melanocytes. Arch Dermatol Res 2009; 302:301-6. [PMID: 20033192 DOI: 10.1007/s00403-009-1012-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2009] [Revised: 11/27/2009] [Accepted: 12/01/2009] [Indexed: 11/24/2022]
Abstract
Development of vitiligo-like hypopigmentary lesions associated with topical imiquimod has been reported. We hypothesized that mode of action of imiquimod in melanocytes may include triggering of apoptosis resulted in loss of cells, which may be a possible mechanism of imiquimod-induced hypopigmentary lesions. Therefore, we investigated whether imiquimod induces apoptosis of human melanocytes and also whether it modulates expression of apoptosis-related molecules in human melanocytes. Imiquimod treatment induced apoptosis of melanocytes, which was observed by TUNEL assay and Hoechst 33258 staining. Imiquimod-induced apoptosis was further shown by measuring mitochondrial membrane potential in melanocytes. The apoptotic activity of imiquimod was associated with caspase-3, Bcl-2 and mitogen-activated protein kinase expression in melanocytes. These results indicated that imiquimod induces apoptosis of melanocytes. These findings may provide a clue to understand pathogenesis of imiquimod-induced vitiligo-like hypopigmentary lesions.
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Affiliation(s)
- Chul-Ho Kim
- Department of Otolaryngology, Ajou University School of Medicine, Suwon, Korea
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